Inquiry Into Supply and Use of Methamphetamines

Inquiry into Supply and Use of Methamphetamines

Law Reform, Drugs and Crime Prevention Committee

Parliament of Victoria

Briefing Paper by UnitingCare ReGen September 2013

Inquiry into Supply and Use of Methamphetamines

Key points

 Most people who use methamphetamines don’t need treatment or do not present for treatment at specialist Alcohol and other Drug (AOD) services such as ReGen

 The number of those people who do present for methamphetamine treatment at ReGen is increasing – from 6% of total ReGen clients in 2010 to 14% early this year

 Working with this client group is challenging due to: . Behaviours commonly associated with methamphetamine intoxication and withdrawal such as hostility and aggression . Limited treatment service access – this is an issue generally in the AOD system but more acute given a reluctance by some organisations to provide services for this client group . Limited evidence-based treatment options (no effective medications yet; limited effectiveness of psychological therapies - particularly in the earlier stages of withdrawal)

 ReGen provides a comprehensive range of educational and clinical services for this client group (although not exclusively) and their families (including Drug Diversion; Drug Driving; counselling - including forensic; non-residential/residential withdrawal for youth and adults)

 ReGen is constantly reviewing practice and exploring innovative ways to address the treatment and support needs of this client group. This would be enhanced with further research and evaluation support

 This client group is placing significant burdens on families who are increasingly seeking support and advice from ReGen. ReGen has developed a suite of family and child counselling and support services in response.

 ReGen is actively forging collaborative arrangements with other services such as the Aboriginal Health Service and Child and Family Services to facilitate referrals and provide advice on the most effective ways to address the needs of this client group.

Introduction

Uniting Care ReGen is the leading alcohol and other drugs (AOD) treatment and education agency of UnitingCare Victoria and Tasmania. ReGen is a not-for-profit agency, which has been operating since May 1970, providing a range of AOD services to the community. ReGen is committed to the provision of high quality evidence based clinical practice. ReGen’s purpose is to promote health and reduce AOD related harm.

ReGen recognises that the terms of reference for this Inquiry are broad, and cover a range of areas, for example the supply and distribution of methamphetamine, that are outside ReGen’s areas of expertise. Accordingly, ReGen will seek to address the terms of reference that fall inside our area of experience and expertise.

Examine the channels of supply of methamphetamine including direct importation and local manufacture of final product and raw constituent chemical precursors and ingredients

ReGen will not be addressing this due to it being outside our areas of expertise and experience.

Examine the supply and distribution of methamphetamine and links to organised crime organisations including outlaw motorcycle gangs

ReGen will not be addressing this due to it being outside our areas of expertise and experience.

Examine the nature, prevalence and culture of methamphetamine use in Victoria, particularly amongst young people, indigenous people and those who live in rural areas

 Is the use of methamphetamines, particularly ‘ice’ escalating in Victoria? If so, why?  How serious is the issue of crystal methamphetamine (‘ice’) use in Victoria? Is it, as has been stated in some sections of the media, at ‘crisis’ point or is this an exaggeration? How does this compare to the use of other drugs including alcohol?  What is the profile/s of the clients with problematic methamphetamine use that your agency is seeing?  Are there any particular groups amongst your clients that are at (high) risk from problematic methamphetamine use?

The following ReGen data is based on methamphetamine users who self-refer for assessment/treatment, or who have been ordered into one of our diversion programs, The number of presentations has more than doubled in recent years. In 2010/11, presentations for primary amphetamine treatment constituted 6% of our client group, increasing to 12% in 2011/2012. However, in the last quarter of 2012/2013, amphetamine-related presentations increased to 14%.

Primary Drug of Choice 2005/06 - 2012/13 50% 44% 45% 43% 42% 39% 39% 40% 39% 40% 32% 32% 30% 29% 30% 25% 22% 22% 22%

20% 15% 13% 13% 14% 12% 12% 10% 7% 8% 8% 7% 10% 6% 5% 7% 6% 7%

0% 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Heroin Alcohol Cannabis Ampetamines (Includes Ice)

It should be noted that, whilst ReGen sees a wide range of clients who use methamphetamines, they are not representative of the broad range of methamphetamine users in the wider community. Many will not experience serious problems and others who do will resolve them on their own or with the support of non- specialist services.

ReGen primarily interacts with two distinct groups of methamphetamine users; those who would consider themselves non-problematic ‘recreational’ users (albeit one’s who have come to the attention of police/courts) who have been ordered to attend diversion programs; and people with problematic use including dependence for which they are seeking treatment or have been directed by the court to undergo assessment/treatment.

ReGen is also concerned about the effect problematic drug use has on the family and especially the wellbeing of children. In our experience, methamphetamine users can go through periods of aggression, rage and despondency, which can have significant effects on all family members.

Examine the links between methamphetamine use and crime, in particular crimes against the person

ReGen will not be addressing this due to it being outside our areas of expertise and experience.

Examine the short and long term consequences of methamphetamine use

 What are the consequences of methamphetamine use, particularly ‘ice’ that your clients are experiencing? Is it as ‘addictive’ as some sections of the media/public advocate? Conversely is ‘ice’ used as an occasional ‘social’ or recreational drug?

Clients participating in ReGen’s diversion programs, who often describe their use as ‘recreational’ report the following positive and negative consequences of methamphetamine use:

Positive

- Increased occupational functionality due to the energy & wakefulness generated by methamphetamine use - Intensified feelings of sociability - General feelings of wellbeing (‘feels good’) - Increased sexual pleasure

Negative

- Periods of low mood and exhaustion following drug use (‘crashing’) - Sleep deprivation - Lack of judgement (e.g. driving whilst intoxicated; gambling) - Difficulty managing social functions such as relationships, employment and education - Legal problems - Feelings of anxiety and depression - Poly drug use

The long-term consequences of methamphetamine use are more likely to be reported by those seeking treatment for their problematic methamphetamine use. Problems include:

- Mental health issues including psychosis and severe depression leading to suicidality - Extreme stress being placed on the family unit - Either being either the perpetrator or victim of violence - Financial stress - Legal problems - Difficulty maintaining employment - Mixing within criminal networks

These clients also reported a range of physical health problems including:

- Dental problems - Deterioration in physical appearance - Nutritional deficits leading to health problems

Examine the relationship of methamphetamine use to other forms of illicit and licit substances

 Is poly drug use a problem in the context of methamphetamine use? If so, what other drugs including alcohol are being taken in association with methamphetamines? What are the consequences of this?

Poly drug use including methamphetamine use was reported across our client groups and this is typical of people presenting for AOD specialist treatment. A range of drugs are used with methamphetamine, for a variety of reasons. Clients talk about using methamphetamine with other stimulants such cocaine or ecstasy- type substances, as well as using a range of depressant drugs e.g. alcohol, cannabis, benzodiazepines and opiates to manage mood or withdrawal symptoms.

Poly drug use can intensify the harms associated with drug use. Not only do different substances have different effects, the combination of them can lead to serious harm and increase the likelihood of unpredictable effects.

Review the adequacy of past and existing state and federal strategies for dealing with methamphetamine use

 How effective have past and current strategies and policies been in Victoria for addressing methamphetamine use?

ReGen recently carried out a wide literature review of state, federal and international strategies for dealing with methamphetamine use, and has concluded the following:

- Many AOD treatment services are not well prepared to offer services to this group of users – they lack confidence and express pessimism about treatment outcomes. - The rate at which people present for treatment in the specialist service system is low and one of the reasons cited for this by methamphetamine users is a lack of confidence in what the services can offer. - Specific withdrawal treatment medications are not yet available and psychological treatments such as cognitive behavioural therapy (CBT), motivational enhancement therapy (MET) and contingency management (CM) have not been tested during the early phases of withdrawal and are only moderately effective in later stages of treatment.

Consider best practice strategies to address methamphetamine use and associated crime, including regulatory, law enforcement, education and treatment responses (particularly for groups outlined above)

 What treatment options do you provide for people with chronic or problematic drug amphetamine/methamphetamine use? Are these specialist or generalist treatment modalities (ie focused on methamphetamine specifically or drugs more broadly). How effective are those treatment options?

 Specifically, how successful has your Residential Methamphetamine Withdrawal Program been? What problems has the program encountered and how could it be improved?

 Can interventions, including education programs aimed at methamphetamine use (including treatment options) be better tailored to specific groups such as young people, Indigenous people, people in rural areas of Victoria or other potentially high risk groups?

 What strategies should be put in place to best address the issue of methamphetamine abuse in Victoria, particularly amongst young people, Indigenous people, and people from rural communities? What could the Committee recommend in this respect?

Working to meet the needs of specific groups:

Aboriginal methamphetamine and other drug use

Our partnership with the Aboriginal Health Service has highlighted that methamphetamine use is a significant problem in the Aboriginal community and we are working together to improve treatment access, treatment suitability and retention rates for this group.

Family members of methamphetamine users

ReGen provides a range of services for families including single counselling sessions, education groups and family counselling. Methamphetamine use of family members is putting pressure on all of these services. Parents seeking assistance from ReGen are increasingly reporting violent and aggressive behaviour by their substance using adolescent and adult children related to methamphetamine use. Very often these family members are residing in the family home. There are limited supports for families in these circumstances and they are often reluctant to exit them from the home or use available legal responses (intervention orders, involving police etc.), given that they recognise and are concerned about the vulnerabilities associated with substance abuse and/or mental health issue (including psychosis). This is a significant challenge for families and ReGen clinicians working with them.

There appears to be a trend of including families in bail conditions and other orders. This may take the form of curfews and parental reporting obligations if breaches occur or limitations on the substance user that have implications for family members (for example an adolescent client who was prohibited from using public transport as part of his order – his working mother was forced to drive and pick him up from school each day). This obviously places significant emotional and practical burdens on families already under pressure.

Families where children may be vulnerable

ReGen has forged a number of partnerships (such as collaboration with Child and Family Services in the Northern Metropolitan Region) where we provide secondary consults to workers who are engaged with families where drug use potentially places children at risk.

ReGen services for methamphetamine users generally

Counselling

ReGen provides a range of counselling services for the increasing number of methamphetamine users who are self-referred or subject to a court order. Counselling provides the opportunity to assist clients to rebuild lives that have been adversely by drugs. It is our experience that methamphetamine users on court orders are relapsing at high rates, reoffending and breaching their Orders.

Non-residential withdrawal

The ReGen non-residential withdrawal team supports methamphetamine users to withdraw from the drugs at home with family and General Medical Practitioner support. This can be challenging for clients (craving can be intense and relapse rates high); for families who are very concerned and needing support in the face of hostile and sometimes violent behaviour; and for clinicians being able to provide the high levels of support (for clients and families) and monitoring the medical and mental health aspects of the withdrawal process.

Residential withdrawal

ReGen has only recently reviewed the residential services that we provide for adult methamphetamine users. The following is an account of our clinical experience and research that led to changes to the services offered. It also outlines future challenges and ways that we believe they can be addressed.

ReGen’s 12-bed residential withdrawal service (Curran Place – Heidelberg) is designed to address withdrawal issues associated with a wide range of drug types and often poly drug use. Its broad goals are:

 Safe and effective withdrawal from the drug(s) of concern  Improvement in physical and mental health  Development of post withdrawal treatment plans

As the number of methamphetamine users admitted for a residential withdrawal increased at ReGen in recent years, clinical staff raised a number of concerns. Staff observed that:

 Participation in the program was poor and encouragement to participate was often met with a hostile response. Participation was often under duress.  Serious incidents involving aggression, threats and property damage, although fairly rare, were on the rise.  Retention of methamphetamine users in the program was poor with 48% not completing the withdrawal episode. This contrasted with higher retention for younger methamphetamine users at ReGen’s youth residential withdrawal facility (Williams House) where non-completion rate was 10%.  Clients often self-discharged or were discharged in an agitated state by staff.  Staff stress and frustration were issues that needed to be addressed.

Following these observations, a decision was made to change a number of key program areas and for these to be monitored for six months between December 2012 and June 2013. Expectations of program participation were relaxed, based on a predicted amphetamine ‘crash’ period. This applied for the first 48 hours (or up to 72 hours for higher withdrawal severity) after admission and clients were given the opportunity to rest in bed with close monitoring and active support if they chose. During this period the emphasis was on the provision of good withdrawal support for this group that included minimising stimulation, ensuring a safe environment, providing support and reassurance, and avoiding confrontations. It also included nursing functions such as monitoring vital signs, mental state, cravings, fluid intake and sleep duration and quality. Symptomatic medications were provided for issues such as agitation/anxiety and sleep disturbance as required.

Clients were closely monitored in terms of their withdrawal state using the Amphetamine Cessation Symptom Assessment (ACSA) tool, a self-administered tool that measures the subjective experience of withdrawal over the previous 24 hour period. 24 clients withdrawing from methamphetamine were evaluated during this six month period, and at the conclusion of the period a retrospective client file audit was conducted. At the end of this time, ReGen found that program retention for methamphetamine clients had increased from 48% to 60% after the program changes were made. One unexpected finding from the client file audit was that ACSA- measured withdrawal symptoms experienced by 50% of clients (n – 6) who completed the 7-day program had increased from their day of admission. The expectation was that there would be a downward trend for all (or the vast majority of) clients over the seven-day period, but all those who experienced symptom reductions by day seven still reported low-moderate withdrawal symptoms. For those who did not complete the 7 day period (n-18), subjective experience of withdrawal severity was high or had increased for some, but for others it was low or had decreased. In other words there was no consistent relationship between high or increasing ACSA scores and early treatment termination.

ReGen has concluded that a seven day withdrawal program may be insufficient for many clients given the evidence that the acute phase may extend for 7 -10 days and a sub-acute phase continuing for a further two weeks. The increase in withdrawal severity for some clients over this short withdrawal time period, albeit based on very small numbers is interesting and warrants further investigation. From a clinical perspective it highlights the need for close symptom monitoring and psychological and medication management.

Conclusions reached were that it was important to allow this client group to ‘crash’ for the first few days. Allowing more rest and reducing demands on these clients in those first few days served to reduce the negative interactions between clients and staff. While clinical experience suggests that early involvement in a structured program does have benefits, it is likely to be less so for this client group. The effects of methamphetamine cessation and the drug/withdrawal effects means that is highly unlikely that clients would benefit from such involvement and nor would other clients and program staff. This is consistent with the experience of other service providers

Adopting best clinical practice is a function of being aware of the scientific literature (including making judgements about quality and relevance to local circumstances) and being willing and able to adjust clinical practice accordingly. The research in this area is very limited and lacks rigour. The clinical literature on which a practice consensus could be formed is also sparse. Resources for trialling new, more flexible approaches are also very limited. Therefore, while ReGen has demonstrated a willingness to implement evidence-based models and strategies, there are currently serious barriers to doing so with this client group.

ReGen believes that drug treatment should only be offered in the context of a robust, evidence-informed treatment and support plan. In the absence of good treatment technologies, we need to be realistic about treatment outcomes. We also need to appreciate the challenges associated with treatment provision and give emphasis to the physical and psychological safety of the client, other clients, family and staff.

ReGen’s experiences in working in this area indicate that more needs to be done to improve the methamphetamine withdrawal experience. The recommendations that we made in the report on our residential methamphetamine withdrawal evaluation and experiences were as follows:

 Further research to assist the development of withdrawal service models and treatment strategies to better address the needs of this client group.

 Extended withdrawal duration (up to 28 days) for some, based on clinical need. This would require some flexibility in episode of care funding. It would also require a different program and cordoned-off beds in the residential facility. The withdrawal duration would be an individually tailored mix of residential and non-residential care (see next).

 Trial of a well-resourced stepped model of care. (eg. GP and non-residential nurse support in the home during the ‘crash’ – residential – non-residential care). Or variations of this model based on need.

 Establish a post-withdrawal 28-day therapeutic program specifically for this client group (allowing a seamless link between withdrawal and post-withdrawal rehabilitation).

 Develop a partnership arrangement to ensure capacity to provide suitable services (such as the 28- day program above) to meet the treatment and support needs of Aboriginal clients.

 Ongoing professional development to improve knowledge and skills to treat this client group.

Summary

The demand for methamphetamine treatment is increasing and the capacity of the AOD system to respond accordingly is limited. ReGen provides a wide range of education, treatment and support programs for this client group and family members. We also work in partnership with other agencies that are struggling to respond to methamphetamine–related issues as they arise in their client groups.

ReGen is committed to providing services to this client group and their families; however there are many challenges to overcome. These include the challenging behaviours that are sometimes displayed by clients using this drug type; high service demand and service access issues; limited research to guide clinical practice; the capacity of the current treatment models and available resources to provide appropriate care; and the capacity of the service to provide expert secondary consultation services to other providers.

About ReGen

Our purpose is to promote health and reduce alcohol and other drug related harm.

ReGen is the lead Alcohol and Other Drugs (AOD) treatment and education agency of UnitingCare Victoria and Tasmania. ReGen is a not-for-profit agency, which has over 40 years experience delivering a comprehensive range of AOD treatment and education services to the community.

These services include Counselling and Support, Assessment and Intake, Community Outpatient, Home-based and Residential Withdrawal for adults and youth, Supported Accommodation, Drug Diversion programs, Youth and Family Services, an Intensive Playgroup, Alcohol Community Rehabilitation Program and AOD services at Port Phillip Prison. ReGen also delivers Education and Training programs nationally.

UnitingCare ReGen, 26 Jessie St, Coburg, VIC 3058 Australia

Tel: +61 (0)3 9386 2876 Fax: +61 (0)3 9383 6705

Email: [email protected] Website: www.regen.org.au

http://twitter.com/ReGenUC